2019-448-E Aging - Charles House Association adult day care

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DocuSign Envelope ID: DBE71181-5A2C-4DC5-B867-8C8C1FCB2DCF 76/20/2019 E(MM/DD/YYYY) AC"RID� CERTIFICATE OF LIABILITY INSURANCE �� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT Michael Riggsbee,Jr. Carolina National Insurance Agency PHONE (919)636 3252 a/c No PO Box 1028 E-MAIL-ADDRESS: -MAIL Jk i ue cna enc ADDRESS: � 9 Y.com INSURERS AFFORDING COVERAGE NAIC# Carrboro NC 27510 INSURER A: Philadelphia 18058 INSURED INSURERB: Carolina Mutual Insurance Company 14090 Charles House Association INSURER C: 7511 Sunrise Road INSURERD: INSURER E: Chapel Hill NC 27514 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD SUER POLICY NUMBER MM/DD/YYWI (MM/DDIYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 \/ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A Y PHPK1958555 05/10/2019 05/10/2020 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY PRO ❑ PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COEaMBINED ccidentS INGLE LIMIT $ 1,000,000 a ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED PHPK1958555 05/10/2019 05/10/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESSLLIAB CLAIMS-MADE PHUB669036 05/10/2019 05/10/2020 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER Y/N OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? N/A N WC23000-2019 06/25/2019 06/25/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 Professional Liability Each Claim $1,000,000 A PHPK1958555 05/10/2019 06/10/2020 Aggregate $3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Government ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough, NC 27278 Fax: Email: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD